Beneficiary Signature: If you are the authorized representative, you must sign above and provide the following information:

Transcription

1 SCOPE OF SALES APPOINTMENT CONFIRMATION FORM To be completed by person with Medicare. Please initial below in the box beside the plan type that you want the agent to discuss with you. If you do not want the agent to discuss a plan type with you, please leave the box empty. (Please note that an agent may also discuss a Medicare Supplement policy with you.) Stand-alone Medicare Prescription Drug Plans (Part D) Medicare Prescription Drug Plan (PDP) A stand-alone drug plan that adds prescription drug coverage to the Original Medicare Plan, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. Medicare Advantage (Part C), Medicare Advantage Prescription Drug Plans, and other Medicare Plans Medicare Health Maintenance Organization (HMO) A Medicare Advantage Plan that must cover all Part A and Part B health care. In most HMOs, you can only go to doctors, specialists, or hospitals in the plan s network except in an emergency. Medicare Preferred Provider Organization (PPO) Plan A type of Medicare Advantage Plan available in a local or regional area in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost. Medicare Private Fee-For-Service (PFFS) Plan A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan s payment and terms and conditions. Medicare Special Needs Plan (SNP) A special type of Medicare Advantage Plan that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical conditions. Medicare Medical Savings Account (MSA) Plan MSA Plans combine a high deductible Medicare Advantage Plan and a bank account. The plan deposits money from Medicare in the account. You can use it to pay your medical expenses until your deductible is met. Medicare Cost Plan A type of health plan. In a Medicare Cost Plan, if you get services outside of the plan s network without a referral, your Medicare-covered services will be paid for under the Original Medicare Plan (your Cost Plan pays for emergency services, or urgently needed services). S5601_09_80007A

2 Scope of SilverScript Appointment Confirmation Form (cont d.) By signing this form you are agreeing to a sales meeting with a sales agent to discuss the specific types of products you initialed above. The person that will be discussing plan options with you is either employed or contracted by a Medicare health plan or prescription drug plan that is not the Federal government, and they may be compensated based on your enrollment in a plan. Signing this form does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan. Beneficiary Signature: If you are the authorized representative, you must sign above and provide the following information: Name: Address: Phone Number: Relationship to Beneficiary: To be completed by Agent: Agent Name: Beneficiary Name: Agent Phone: Beneficiary Phone: Beneficiary Address: Initial Method of Contact: (Indicate here if beneficiary was a walk-in.) Agent s Signature: Date: Time: Instructions for agents: If you are doing a sales presentation to a beneficiary, you MUST have a documented scope of what you will be discussing with the beneficiary prior to the appointment. A beneficiary can not agree to the scope over the phone and sign the documentation later. Documentation must be in writing in the form of a signed document by the beneficiary or a recorded phone call. You must send this documentation with the enrollment form to SilverScript.

3 P.O. Box , Nashville, TN Dear Prospective Member, Thanks for your Interest in SilverScript Insurance! Your agent (i.e. the person who is providing this kit to you) is marketing on behalf of SilverScript Insurance Company a Prescription Drug Plan (PDP) sponsor to provide you with information on Medicare Part D prescription drug coverage. Medicare has approved our plans to provide prescription drug coverage in all 50 states, the District of Columbia and Puerto Rico. We have designed our plans to be as easy and convenient as possible for you. Medicare Part D Overview Part D Coverage is available to everyone who is entitled to Medicare Part A or enrolled in Part B. You have various choices for the available plans in your area. You should compare the plans carefully, because while all Part D plans are required to be approved by Medicare (the Centers for Medicare & Medicaid Services), not all Part D plans are the same. Some of the differences between plans are: Covered drugs The monthly premium The annual deductible and cost sharing Which pharmacies are in the plan s nationwide network The Medicare Part D benefit is much like other insurance policies you may have. There is a monthly premium, cost sharing responsibility for covered drugs, and the plan will pay the rest of your covered drug costs. Pick the Plan that is Right for You Our plans have premiums, deductibles, and cost sharing to fit your needs. Whether you want to just budget your monthly premium or control your annual prescription drug expenses; whether you are enrolling with us for the first time or are renewing your plan, we are here to make your decisions easier. We offer three different prescription drug plans that deliver value based on your prescription drug needs. Our plans are: SilverScript Value (PDP) This plan offers prescription drug coverage at low-monthly premiums and is designed for Medicare-eligible beneficiaries who take a few prescriptions but want peace of mind knowing their plan provides comprehensive coverage should their health needs change. CVS Caremark Plus (PDP) Designed for Medicare-eligible beneficiaries who prefer brand-name drugs and a lower annual deductible. This product offers lower co-payments for some brands (Value Tier Brands) and many generics (Value Tier Generics) at preferred retail and preferred mail pharmacies. Other pharmacies are available in our network S5601_10_20004 CMS Approval Date: 10/05/2009

4 CVS Caremark Complete (PDP) Tailored to Medicare-eligible beneficiaries who prefer generics, no deductibles, and coverage in the donut hole. This plan also has lower co-payments for value tier generics at preferred retail and preferred mail pharmacies. To help beneficiaries with reducing their out-of-pocket costs, this Plan covers generics through the coverage gap with significantly lower co-payments available at preferred retail and preferred mail pharmacies. There are many Medicare Part D plans to choose from in your area, so please review these materials carefully before selecting a plan. Along with this letter you will be given: An Easy-to-Use Enrollment Form Simply select the plan that best fits your needs, fill out and sign the form, and give the signed form back to your SilverScript agent. Keep a copy for your records. You may also enroll online on our Web site at sms.silverscript.com. Please note that Medicare beneficiaries enrolled in an Medicare Advantage (MA) private fee for service (PFFS) plan that includes Medicare prescription drugs or any MA coordinated care (HMO or PPO) plan will be automatically disenrolled from the HMO, PPO or MA PFFS plan if they enroll in a PDP such as one of our plans. Medicare beneficiaries enrolled in a MA PFFS plan that does not include Medicare prescription drug coverage, an MA Medicare Savings Account (MSA) plan or an 1876 Cost plan may enroll in a PDP such as one of our plans and will not be automatically disenrolled from the PFFS, MSA or 1876 Cost Plan. The SilverScript Insurance Medicare Prescription Drug Coverage Plans As a member in one of our plans, we want to be sure you receive the best of safety, savings and service. We are a Medicare approved plan that contracts with the Federal government. Some features of our plans include: 24x7 Customer Service Tools Our plans all offer customer service and a Web site both are available to our members 24 hours a day, 7 days a week. Co-Payments vs. Co-Insurance To make budgeting for your prescription medications easier, we offer a co-payment versus a co-insurance amount, which means fewer confusing calculations, on most of your prescription drugs. You always know what you will pay for your medications before you go to the pharmacy. National Plan Accessibility We offer prescription drug coverage in all 50 states, Washington D.C. and Puerto Rico. Even if you move to another state, you can keep SilverScript Insurance as your prescription benefit provider by enrolling in one of our plans available in your new location. This allows for an easy transition into your new location with uninterrupted service. If you move from one state to another, you will need to contact us to update your enrollment information and, if necessary, enroll you into a SilverScript Insurance plan in your new location; otherwise you may be disenrolled from the plan. Robust Pharmacy Network More than 64,000* pharmacies nationwide make up the pharmacy network. These include retail, mail service, long-term care, home infusion, and Indian Health and Indian Tribal pharmacies. You must use a network pharmacy in order to receive full benefit coverage on your prescriptions. If you need to check if a pharmacy is in our network, just call Customer Care at TTY users should call Other pharmacies are available in our network

5 Online Document Library As one of our members, we offer you the choice of accessing all your plan documents electronically instead of receiving printed versions in the mail. Reduce your mail clutter, be green and have access to your documents securely 24 hours a day, 7 days a week. By signing up for this service, you will be able to view, download and save your documents sooner and not have to wait for them to arrive in the mail. What are my protections in this plan? As a member of one of our plans, you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. All Medicare Prescription Drug Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. SilverScript Insurance Company can choose to not renew its contract with CMS and CMS may also refuse to renew the contract, thus resulting in a termination or non-renewal. This may result in termination of your enrollment in the plan. In addition, SilverScript may reduce its service area and no longer offer services in the area where you reside. Even if SilverScript Insurance Company leaves the program, you will not lose Medicare prescription drug coverage. If SilverScript Insurance Company decides not to continue, it must send you a letter at least 60 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. Value Added Services Just being a member of one of our plans provides you with extra value and various ways to enjoy safety, savings, and service. Once you become a plan member, you will receive an ExtraCare Health card, which entitles you to a 20% discount on CVS/pharmacy brand health-related products. You can use your ExtraCare Health card at more than 6,900** CVS/pharmacy stores nationwide. The value added products and services described above are neither offered nor guaranteed under our contract with Medicare. In addition, they are not subject to the Medicare appeals process. Purchases eligible for the ExtraCare Health card will not count toward your true-out-of-pocket expense (TrOOP) amounts. Any disputes regarding these products and services may be subject to the SilverScript Insurance grievance process

6 Do you Qualify for Extra Help? People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for seventy five (75) percent of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don t even know it. For more information about this Extra Help, contact your local Social Security office or call MEDICARE ( ), 24 hours per day, 7 days per week. TTY users should call We Look Forward to Serving You Providing quality service to you is our focus. If you have questions about this information or need help to enroll in one of our plans, please contact us at from 8:00 a.m. to 2:00 a.m. ET, 7 days a week. TTY users should call You can also contact your agent at from 8:00 a.m. to 2:00 a.m. ET, 7 days a week. Or visit our Web site at sms.silverscript.com. The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you may use the web tools on and select Compare Medicare Prescription Drug Plans or Compare Health Plans and Medigap Policies in Your Area to compare the plan ratings for Medicare plans in your area. You can also call us directly at to obtain a copy of the plan ratings for this plan. TTY users call If you have other questions, you may contact MEDICARE ( ), or visit for more information about Medicare benefits and services, including general information regarding the health or Part D benefit. Sincerely, Lloyd D. McDonald President, SilverScript Insurance Company Your agent, i.e. the person who is providing this kit to you, with whom you may discuss your enrollment, is marketing on behalf of SilverScript Insurance Company and is compensated based on your enrollment in the plan. * ** As of 6/2009, Caremark Network Services states there are more than 64,000 contracted network pharmacies nationwide. As of 6/2009, Caremark Network Services states there are more than 6,900 CVS pharmacies nationwide. Para recibir esta información en otro formato, como en español, póngase en contacto con nosotros al

7 P.O. Box 52067, Phoenix, AZ MEDICARE PRESCRIPTION DRUG PLAN INDIVIDUAL ENROLLMENT FORM To Enroll in SilverScript Insurance Medicare Part D Prescription Drug Plan, Please Provide the Following Information Please check which plan you want to enroll in. SilverScript Value (PDP) $31.10 per month CVS Caremark Plus (PDP) $43.50 per month CVS Caremark Complete (PDP) $63.40 per month LAST Name FIRST Name Middle Initial Mr. Mrs. Ms. Birth Date ( / / ) Sex M F Address [Optional] Home Telephone ( ) Permanent Residence Address (P.O. Box is not allowed) City State ZIP Code Long-term Care Facility Telephone ( ) Mailing Address (if different from Permanent Address) City State ZIP Code [Optional] Emergency Contact: Telephone Relationship to You Please Provide Your Medicare Insurance Information Use your Medicare Card to complete this section. - OR - Please fill in these blanks so they match your red, white and blue Medicare card Attach a copy of your Medicare card or your letter from the Social Security Administration or Railroad Retirement Board. You must have Medicare Part A or Part B (or both) to join a Medicare prescription drug plan. Name: Medicare Claim # Sex - - Is Entitled To Effective Date HOSPITAL (Part A) MEDICAL (Part B) Other Pharmacies are Available in our Network S5601_10_30005b_9403_7218_028,029,085 Approved by CMS 10/06/2009 Page 1 of 3

8 Paying Your Plan Premium Payment Options People with limited incomes may qualify for extra help to pay for their prescription drug costs. If you qualify, Medicare could pay for 75% of drug costs including monthly prescription drug premiums, annual deductibles and co-insurance. Additionally, those who qualify won t have a coverage gap or a late enrollment penalty. Many people are eligible for these savings and don t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at TTY users should call You can also apply for extra help online at If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If you have a remaining premium, please select an option below to pay the remaining premium balance. Please select a premium payment option. (If you don t select an option, you will receive a monthly bill.) Receive a monthly bills that you can pay by mail Reminder, in order to have secondary coverage applied correctly (example: from your employer or an SPAP) beneficiaries must choose monthly bills that you can pay by mail for premiums. Automatic deduction from your Social Security check Automatic deduction from your Social Security Check may take two or more months to begin and your first deduction will include all premiums due from your enrollment effective date to your first deduction. Please Answer the Following Questions Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs. Will you have other prescription drug coverage in addition to SilverScript? Yes No If yes, please list your other coverage and your identification (ID) number(s) for this coverage below. Name of other coverage ID # for this coverage Group # for this coverage Would you like to receive this information in Spanish? Y N Le gustaría recibir esta información en español? Y N To receive information in another language or in an alternate format, please call us at: , 24 hours a day, 7 days a week. TTY: Please Read This Important Information If you are a member of a Medicare Advantage Plan (like an HMO or PPO), you may already have prescription drug coverage from your Medicare Advantage Plan that will meet your needs. By joining SilverScript Insurance your membership in your Medicare Advantage Plan may end. This will affect both your doctor and hospital coverage, as well as your prescription drug coverage. Read the information that your Medicare Advantage Plan sends you and if you have questions, contact your Medicare Advantage Plan. If you currently have health coverage from an employer or union, joining SilverScript Insurance could affect your employer or union health benefits. You could lose your employer or union health coverage if you join SilverScript Insurance. Read the communications your employer or union sends you. If you have questions, visit their Web site, or contact the office listed in their communications. If there isn t information on whom to contact, your benefits administrator, or the office that answers questions about your coverage can help. S5601_10_30005b_9403_7218_028,029,085 Approved by CMS 10/06/2009 Page 2 of 3

9 Please Read and Sign Below By completing this enrollment application, I agree to the following: SilverScript Insurance is a Medicare drug plan and has a contract with the Federal government. I understand that this prescription drug coverage is in addition to my coverage under Medicare; therefore, I will need to keep my Medicare Part A or Part B coverage. It is my responsibility to inform SilverScript Insurance of any prescription drug coverage that I have or may get in the future. I can only be in one Medicare prescription drug plan at a time if I am currently in a Medicare prescription drug plan, my enrollment in SilverScript Insurance will end that enrollment. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes if an enrollment period is available, generally during the Annual Enrollment period (November 15 December 31), unless I qualify for certain special circumstances. SilverScript Insurance serves a specific service area. If I move out of the area that SilverScript Insurance serves, I need to notify the plan so I can disenroll and find a new plan in my new area. I understand that I must use network pharmacies except in an emergency when I cannot reasonably use SilverScript Insurance network pharmacies. Once I am a member of SilverScript Insurance, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from SilverScript Insurance when I get it to know which rules I must follow to get coverage. I understand that if I leave this plan and don t have or get other Medicare prescription drug coverage or creditable prescription drug coverage (as good as Medicare s), I may have to pay a late enrollment penalty in addition to my premium for Medicare prescription drug coverage in the future. I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with SilverScript Insurance, he/she may be paid based on my enrollment in SilverScript Insurance. Counseling services may be available in my state to provide advice concerning Medicare supplement insurance or other Medicare Advantage or Prescription Drug Plan options, medical assistance through the state Medicaid program and the Medicare Savings Program. Release of Information: By joining this Medicare prescription drug plan, I acknowledge that SilverScript Insurance will release my information to Medicare and other plans as is necessary for treatment, payment, and health care operations. I also acknowledge that SilverScript Insurance will release my information, including my prescription drug event data, to Medicare, who may release it for research and other purposes that follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on my behalf under State law where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request by SilverScript Insurance or by Medicare. Please sign below to certify that you have read, understand and agree to the conditions written above. Signature If you are the authorized representative, sign above and complete the information below. Name Address Telephone Relationship to Enrollee S5601_10_30005b_9403_7218_028,029,085 Approved by CMS 10/06/2009 Today s Date Medicare Prescription Drug Plan Use Only Client ID # 7218 Plan ID # Agent ID # SMS Agent Signature MP ID # Date of Coverage: IEP: AEP: SEP: Page 3 of 3